Language is Important – A Reply to Ronald Pies

Dr. Ronald Pies is, characteristically,
correct in pointing out that language is important. Elegant language should be
used to explain and contextualize the evidence of empirical research, not to
obfuscate and not to serve as an alternative to scientific analysis. So I am
sorry that Dr. Pies was confused, rather than inspired, by my essay. He raised several important
questions that I had clearly failed to address adequately. In particular, Dr.
Pies suggested my essay was extraordinarily broad and entirely unreferenced; if
I had explained myself better, I’m hopeful that Dr. Pies might have found more
with which to agree.

These issues have been discussed…
quite a lot recently, and we could end up repeating ourselves. So I won’t just
refer to sources of those missing references (especially books by Richard Bentall,
Jo Moncrieff
and John Read and
Jacqui Dillon), but also engage with Dr. Pies’ specific questions.

First, Dr. Pies asked what I meant
by a “psychiatric diagnosis”? He asked whether that referred “to any
diagnostic conclusion reached by an experienced psychiatrist? To any or all
DSM-IV or DSM-5 criteria sets? If a social worker diagnoses
“obsessive-compulsive disorder”, does that constitute a “psychiatric”
diagnosis?” The answer, in brief, is “yes”, that sounds like a fair
conclusion. I certainly don’t think that psychiatrists, as a profession, make
flawed diagnoses and that other professions, such as social workers are somehow
more (or less) skilled. I mean quite the reverse – that the theoretical approach,
the carefully-crafted tools, and, specifically, the DSM-IV, DSM-5 and ICD
criteria sets actively hinder caring and skilled clinicians as they try to
understand and help their clients.

(Un)reliability

I’m genuinely appreciative that
Dr. Pies set out his questions so clearly. Unfortunately – or perhaps rather
positively – there are complexities in the answers that mean we have a lot to
discuss. So Dr. Pies next asked whether I was aware “that the inter-rater
reliability (kappa) of several psychiatric diagnoses has been shown to be
comparable to, or better than, some diagnoses in pathology and internal
medicine, when structured clinical interviews are used?” (and cited a specific
paper).

So… I am aware that medical
diagnoses are not perfect. I am, in fact, mildly concerned about the fact that
I and my family put a great deal of trust in the judgment of medical
professionals (and take medication as a consequence) without necessarily
testing out possible alternatives. In general practice, for example, there have
been a number of trials (with varying success) of the use of computerized
‘expert systems’ to take out the vagaries of human judgment.

In the field of psychiatry, my
point was not to contrast the difficulties of the psychiatric diagnostic
process with the supposed simplicities of ‘medical’ diagnosis – but to contrast
the inadequacies of psychiatric diagnoses with a proposal for a problem-focused
approach. Drawing this comparison is important and was the main point of my
essay. Indeed, it might have been helpful – for me – if Dr. Pies had actually
addressed this. Does he think, for example, that diagnosis adds clinical
utility over and above the problem-focused approach I have described? And if so, what is this
benefit?

But also… it’s interesting that
Dr. Pies focused on four very high kappa coefficients from DSM-III. Because, of
course, the kappa coefficients for ‘post-traumatic stress disorder’ (0.55) or
‘attention deficit disorder’ (0.50) or even ‘autistic spectrum disorder’ (0.01)
are not so robust. And it’s interesting that we’re talking about DSM-III
diagnoses, because the inter-rater reliability for the DSM franchise has been falling…
as they refine the brand, its performance drops.

But even despite this
cherry-picking, I think that Dr. Pies and colleagues are in danger of comparing
apples with pears. One study that Dr. Pies refers to compares the ‘high’
reliability of psychiatric diagnoses with the poorer reliability of medical
diagnoses by looking at inter-rater agreement in stroke patients. But the
two kappa coefficients being discussed refer to different things. In relation
to the DSM-III, the kappa coefficients refer to two clinicians agreeing (or
not) whether a particular putative disorder is present – whether the criteria
are met for its diagnosis. The kappa coefficients in the stroke paper refer to
raters agreeing not on whether there has been a stroke or not, but on its
aetilogy (comparing “atherosclerotic large-vessel disease, lacunar infarct,
cardioembolic stroke, stroke of other known cause, and stroke of undetermined
etiology”).

In reference to my claim that
psychiatric diagnoses “fail to predict the course of a person’s problems”, Dr.
Pies pointed out that “several studies of DSM-defined schizophrenia have
shown good predictive validity”. That’s a very fair point. There have been
several studies along these lines, and it’s absolutely true to say that if you
first receive a diagnosis of schizophrenia, then, 13 years later, you are much
more likely still to meet that diagnosis (although there are some differences
between the different diagnostic systems). But that wasn’t quite what I was,
perhaps inelegantly, groping at.

I wasn’t suggesting that a person
could experience a random collection of problems at one point in time and
experience an equally random and unrelated variety of difficulties at a second
time. I believe that a person’s difficulties will have structure and meaning,
and have explicable aetiological causes. So if people experience hallucinations
(let’s say) at one point in their lives, it is not particularly surprising that
they experience hallucinations later. This merely speaks to the fact that human
experiences are understandable and non-random, but does not necessarily speak
to the existence of a valid syndrome called schizophrenia. Indeed it is very
sad that the consistency across time is as high as is reported. If the
‘treatments’ for the diagnosed ‘disorders’ had been successful, then you would
expect that the problems would be resolved, and you would hope that a few years
later there would be relatively little concordance (if successfully treated,
the symptoms would no longer exist).

But, as I say, I wasn’t suggesting
– this is not our contention at all – that people’s experiences are random. The
point is that diagnoses such as ‘schizophrenia’ do not efficiently predict the
course or outcome for individuals – whether they will remain in hospital,
remain reliant on medication, work, marry, raise children (Ciompi, 1984;
Sartorius et al, 1987).

(Non)indicator
of Treatment Success

And that leads on to treatment, of
course. And I’m afraid, here, Dr. Pies and I may disagree a little more. Dr.
Pies asked whether I “believe that a DSM diagnosis of bipolar I disorder does
not predict, in general, a favorable response to lithium carbonate?” First, and
I’m sorry if I’m repeating myself, the DSM-5 field trials revealed a kappa
coefficient of 0.54 for the diagnosis of bipolar I disorder… so I wouldn’t
place too much faith in the reliability of the diagnosis.

Many of my medical colleagues have
some faith in the effectiveness of lithium carbonate in stabilizing moods
although (as I suspect readers will realize) I would prefer to use other
effective, and less toxic, methods myself. But my argument – our argument –
isn’t to try to undermine and criticize established research. I don’t think
it’s remotely sensible to claim that medication has no effect on our mood, or
that those effects cannot be helpful. But, and probably partly because their
reliability is so low, diagnoses are not as effective in predicting responses
to drugs as are approaches based
on specific problems.

To try to be as clear as possible:
medication can be helpful and medical psychiatrists play a vital role. But they
would be much more effective in helping people if they responded to specific
problems than if they attempted to give the treatments predicated by diagnoses.

This is clearer still in respect
to Dr. Pies’ next question [would I believe that] “a diagnosis of major
depressive disorder fails to predict a good response to cognitive-behavioral
therapy?”. Well… technically, yes… and no. It’s pretty clear (although some
of my colleagues seem to be more skeptical) that CBT is helpful for people with
low mood… but also with a wide range of other problems. That’s understandable.
People make sense of their world. These frameworks of understanding are, in
large part, consequent on the experiences they’ve had, especially in childhood
and adolescence, and how they’ve learned to respond. And, of course, the way in
which people make sense of their world has profound effects on their emotions
and behavior; their “mental health”. So, therefore, it’s entirely unsurprising
that CBT – a pretty straightforward, but highly skillful approach to helping
people examine and change their framework of understanding of the world – is
effective. But, again for entirely unsurprising reasons, CBT is helpful across
a wide range of problems; any problem where a person’s cognitive schema plays a
role (which is, of course, true in many cases).

So CBT is very helpful… but it’s
not a specific treatment for ‘major depressive disorder’. And this, technically
means that while somebody with a diagnosis of major depressive disorder may
well respond well to cognitive-behavioral therapy, so would someone without
that diagnosis. Once again… it’s the identification of problems, not the
diagnosis of illnesses, that’s useful.

Utility

That, then, is what I mean by “psychiatric
disorders have poor ‘utility’”. They aren’t useful over and above simply
focusing on the problems people experience. Two people with the same diagnosis
may have two largely (sometimes completely) non-overlapping sets of problems,
with no established underlying pathology. Proponents of psychiatric diagnosis
argue that a diagnosis is useful for communication, but since the information
doesn’t tell you what problems a person is actually experiencing, doesn’t
specify what treatment will be effective and doesn’t point towards a specific
set of causal agents, I find this claim hard to understand. I worry that what’s
actually being communicated is what Dawkins calls a ‘meme’ – a belief system
(this person is suffering from schizophrenia, and we all know what that means,
don’t we?).

(In)humanity

“What studies can
Prof. Kinderman cite showing that psychiatric diagnoses lack “humanity”? In
what sense is this true?”

Dr. Pies is absolutely correct –
when I refer to ‘humanity’, I’m making a moral judgment. I fear that the
‘diagnosis-treat’ model leads to inhumane treatment. I absolutely do not
believe that my traditional psychiatric colleagues are themselves inhumane, but
I believe that, with great sympathy and with the best interests of their
clients at heart, inhumane practices abound.

Sadly, these experiences are not
limited to UN reports, nor to the stranger shores of experimental therapy.

I receive a fair number of
unsolicited letters. One summed up the situation nicely:

Rather than engaging with the
patients on the ward, the staff instead shepherded them around like sheep with
bullying commands, threats of ‘jabs’ (injections), and removal to an acute ward
elsewhere in the hospital, if they did not co-operate. The staff also stressed
medication rather than engagement as a way of controlling the patients. And the
staff closeted themselves in the ward office, instead of being out and about on
the corridors and in the vestibule where they should have been. The staff wrote
daily reports on each patient on the hospital’s Intranet system; these reports
were depended upon by the consultant psychiatrists for their diagnoses and
medication prescriptions, but were patently fabricated and false, because the
staff had never engaged or observed properly the patient they were writing
about in their reports. The psychiatrists themselves were rarely seen on the
ward, and only consulted with their patients once a week.

Is diagnosis part of this picture?
Unfortunately yes. A few years ago, Erika Setzu and I, together with colleagues
at the University of Liverpool, conducted a simple research study into serious
mental health problems. We asked people who either had been, or were currently,
in great distress and admitted to acute psychiatric units, about their own
understanding of the circumstances of being admitted to hospital. One interview
(with, it’s perhaps important to note, a male participant) went as follows:

Erika: “Do you know why [the
problems began]?”

Interviewee: “No, I don’t know
for certain. I had taken some pot before my first admission and I thought
somebody might have dropped some acid on it. I also had a difficult childhood.
I was physically and emotionally abused, sexually abused as well. This is very
difficult for me to get my head round.”

A little later, the interview
continued:

Interviewee: “I started to hear
voices, but they were not nice voices, they were horrible.”

Erika: “Did you recognise
them?”

Interviewee: “It was the man
that abused me …I met this man that was a builder, in construction, you know?
And he said that he wanted to give me a job, but they were all lies, he was
trying to con me. He took me back to his house, he locked the door and he had
sex with me. … And then other voices as well. I went to … hospital and the nurses
were very good to me.”

Erika: “When you went to
hospital what did they say it was wrong with you?”

Interviewee: “Schizophrenia,
paranoid schizophrenia.”

Erika: “What do you think
personally?”

Interviewee: “What do you mean?”

Erika: “Do you think it is what you’ve got?”

Interviewee: “Oh yes, that’s
what I have got.”

To my mind, the reduction of this
man’s narrative from the understandable consequences of rape to the symptoms of
schizophrenia is inhumane. It is also, as I’ll suggest in a moment, an
epistemological point, too. But I am concerned at how we become uninterested in
what has happened to people and become interested in what they’ve “got” and
what drugs we can give them. The point is that such diagnoses expunge our lived
experiences from the narrative, rendering our stories pointless, and reducing
our human responses to symptoms of illness.

Epistemology

Dr. Pies asked; “What studies
can Prof. Kinderman cite showing that psychiatric disorders have poor
“epistemology”? What can this claim even mean, since epistemology is the branch
of philosophy concerned with the nature and scope of knowledge? How has Prof.
Kinderman measured the quality of the “epistemology” of psychiatric diagnosis?”

In epistemological terms, diagnoses
convey the idea that people’s difficulties can be understood in the same way as
bodily diseases, which excludes the possibility of finding meaning in people’s
‘disordered’ responses and experiences, and thus prevents people from
understanding how they might use their own resources to address their
difficulties. Worse still, diagnoses are used as pseudo-explanations for
troubling behaviours (he did this because he has schizophrenia) without
consideration of the circularity of that argument, and the broader context
(e.g., whether a paranoid person has actually been victimised). And as a result
of all these failings, the diagnostic tools that we are currently living with
mean a person’s social and interpersonal difficulties are often ignored in the
hope that the right medication regimen will achieve the desired return to
normal functioning.

Mapping

Dr. Pies was confused by my use of
the term “mapping”; and asked a few very pertinent questions:

What does Prof. Kinderman mean
when he says that psychiatric disorders “fail to map onto an entity discernible
in the real world?” What sort of “entity” does he have in mind? A lesion? A
bacterium? A damaged section of the brain? Can Prof. Kinderman identify the
“entity” in “the real world” onto which the diagnosis of migraine headache
“maps”? How about chronic facial pain? What is the “entity” onto which the
diagnosis of fibromyalgia “maps”? Do any of these three recognized
disorders/diseases “map neatly onto biological findings”? Or are these not
“real diseases” or disorders in the sense Prof. Kinderman would define these
terms? What does it mean, “to map onto”, anyway? Is this a
scientifically-defined term or merely a metaphor derived from the now largely
discredited school of logical positivism?

Well, first, I can’t comment on
the validity of “migrane”, or “firbrobmyalgia”. But if these disorders do not
have identified biological underpinnings I would start to be skeptical of their
validity. As a scientist, I recognize we might not yet know all there is to
know, but I’d start to be worried if there were no biological abnormality,
disease vector… as indeed we find with many psychiatric disorders, of course.
I’m not a medical doctor, and I trust my medical colleagues are scientific and
skeptical in this regard, but if “migraine” or “firbrobmyalgia” have no
discernable ‘biomarker’, then yes, I’d be skeptical of their validity, too.

The mention of ‘chronic facial
pain’ is very interesting, as that strikes me as exactly the kind of
problem-focused identification of a difficulty that we’re recommending. The
person is experiencing pain, it’s in the face, and it’s chronic. That implies
nothing but identifies the issue. It’s clear, descriptive and makes no
implications as to the underlying nature of the problem. ‘Migraine’ is different,
and begins to make assumptions that need to be justified.

So “mapping onto real world
entities” does include the notion of biomarkers. It also speaks to the
construct validity of psychiatric disorders. That is, when we expose
psychiatric diagnoses to factor analysis or cluster analysis or other
statistical techniques, the wise and careful judgments of committees of experts
turn out to be … wrong. If these diagnoses were valid, we’d see large numbers
of people meeting the criteria for no disorder at all, some people meeting the
criteria for one disorder, but not others, and relatively few meeting the
criteria for more than one. The diagnoses should – in Plato’s phrase – “carve
nature at the joints”. But I think it is hard to argue that they DSM and
ICD achieve this. The reason – as Thomas Insel
recently implied, but others such as Mary Boyle and Richard Bentall
have been saying for years – is that few of the current diagnostic categories
were “discovered” from the bottom-up. Rather, for a variety of reasons that can
be traced historically,
they were largely determined a priori, by committee and not on the
strength of evidence. A recent example of this process in action is the
inclusion of Disruptive Mood Dysregulation Disorder in the DSM 5. It is
acknowledged that this diagnosis lacks validity and specificity and has a weak
basis in empirical research.
It has not been “discovered” by application of the scientific method but
conjured into existence for non-scientific reasons (to solve an embarrassing
problem for the APA, namely the enormous rise in diagnoses of childhood
‘bipolar disorder’ and consequent dangerous proliferation of medication).

What we see (and just one piece of
research below) is a pattern of human experiences which has meaning and
structure… but not support for DSM and ICD diagnoses, no matter how much the
expert committees think constructs such as ‘schizophrenia’ must exist.

Dr. Pies expands these ideas by
asking, “Could it be said that one very relevant real-world “entity” is the
suffering and incapacitated patient, and that at least some psychiatric
disorders actually “map” quite well onto the self-generated description of that
patient’s suffering and incapacity?”

“For example, when a patient
complains of having had, for the past 12 years, command auditory hallucinations
telling him to kill himself; the feeling that his arms are melting into the
chair; the belief that a radio transmitter has been implanted into his brain by
the KGB; that everyone around him can overhear his thoughts, and plant
dangerous thoughts in his mind…”

And to that point I’m completely
in agreement. But Dr. Pies– and this is, in a sense, the problem the point of
the DSM – doesn’t follow his own good advice. He doesn’t stop at the client’s
“self-generated” list of difficulties but insists on applying the (flawed)
logic of a committee of experts… “is there a legitimate and clinically
useful sense in which the DSM-IV or DSM-5 category of schizophrenia “maps” onto
this particular patient’s experience and world-view?” To which the answer
clearly is NO!

We can, we should, work with
self-generated problem-lists. The difficulties arise when, completely
unnecessarily, scientifically unwisely, we insist upon adding meaningless and
misleading committee-generated labels to this useful and valid description of a
person’s problems. The labels necessarily obscure the real nature of the
person’s difficulties. My question to Dr. Pies would be: since clearly
describing a person’s problems seems so helpful, what additional benefit is
offered by a diagnosis?

Dr. Pies points out that I have,
myself, used psychiatric diagnoses. Of course. I would like to see a system
whereby we all study, care for and talk about specific problems. But I don’t
yet live in that world. In the meantime I have to do two things; live in the
reality of the academic and clinical world in which I find myself, and work to
change it.

Ethics

Dr. Pies was intrigued by my
suggestion that “psychiatric diagnoses have ‘ethical failings’” –
meaning that diagnoses are “used as pseudo-explanations for troubling
behaviours.”

I think this does have huge
ethical implications. The best (or perhaps worst) example of this is “coercive
paraphilic disorder”. In any ethical world, if we come across a man who
repeatedly rapes women (or men), I would hope we would try to investigate and
understand all aspects of why this happens. I can conceive of circumstances
where this would lessen the culpability of the individual. But I think there
are huge ethical implications of saying that “the rapes are in fact symptoms of
his ‘paraphilic coercive disorder” or that “he raped because he is suffering
from coercive paraphilic disorder”.

Framing the situation this way implies
that his behaviours were CAUSED by the “disorder” to which the label refers.
But, the idea that there might exist such a disorder did not come about – as we
might reasonably expect – as the consequence of a process of scientific
discovery. The disorder was brought into being by a committee of (as has been
widely noted, financially compromised) experts who share a particular
perspective. For me, this is ethically troubling.

Dr. Pies also was perplexed by the
view that people claim that “psychiatric diagnoses imply that people’s
difficulties can be understood, or ought to be understood, “in the same way as
bodily diseases”.

He’s right of course. This claim
does not square with the “biopsychosocial model”, which has been the
predominant paradigm in American academic psychiatry since George Engel
introduced the term. But [URL] the principles of the biopsychosocial model are
often rather undermined by the tendency to see biological factors as dominant
or ‘primary’. So social factors are often regarded as moderating underlying
genetic vulnerabilities… I think people often find it difficult to think of
genetic factors mediating the effects of social factors (such as abuse) on
outcome… although, in scientific terms, that is of course precisely what’s
happening.

And is it true that people say
that psychiatric problems are essentially the same as bodily illnesses?

Well… I invite readers to explore
this question for themselves. Our beloved Google reveals that the search
“depression is a brain disease” textbook gives us several (actually thousands
of) hits. I’ll offer a prize (really, and it’ll be fantastic) for the best
example. My favorites include Charles Nemeroff
making a typical robust offering… although here he does reveal some of his
stock options. Or “San Diego’s
Voice on Mental Illness” which tells the citizens that depression is
“an Illness Like Any Other: Mental Illnesses are Brain Disorders”. This
is important, of course, because the “an illness like any other” … approach
actually increases stigma.

Am I aware that well-known psychiatric
textbooks promote a much more humane and scientifically valid approach? Of
course. But I would maintain that – as my correspondent above suggested –
that’s what’s SAID. What’s done in practice is often quite different and, in
some cases, quite brutal.